1. Fatigue Jane Hartwell Cumberland Infirmary, Carlisle

2. Fatigue The Syndrome that wears you out!

3. Fatigue should receive the same attention as other symptoms associated with advanced cancer such as pain. However, to develop effective strategies to control fatigue we must first gain a greater understanding of what fatigue is.

4. l It is a BIG PROBLEM for patients

5. Fatigue is multidimensional l In its cause l In its treatment l It is subjective: how a patient perceives and feels about their weakness. l It is measurable: measurable decrease in physical or mental performance

6. Effect on Patients Physiological (acute) Positive effect on body allowing recuperation Pathological (chronic) Negative effects on body- associated with chronic conditions

7. 5 Dimensions to Subjective Fatigue Cognitive sensations reduced concentration memory loss difficulty thinking clearly Affective sensations low mood low motivation anticipatory sensation of difficulty initiating any activity Low energy Physical sensations feeling tired easy tiring reduced capacity to maintain performance Advanced Stage of Fatigue Fatigue of dying Secondary Fatigue The wearying effect of living with fatigue

8. Overview Reported as the most prevalent and disturbing symptom of cancer and its treatment Up to 80-96% of patients receiving chemotherapy, (Richardson (2000) 65-95% of patients receiving radiotherapy experience fatigue (Nail 1993) 60% of patients with cancer claim that fatigue had a major effect on their lifestyle ( Cella, 1993, Vogelzang, 1997)

9. Is fatigue an effect of cancer, cancer treatment or both? Difficult to research, ethically unable to give cancer treatment to patients unless they have cancer. However, survivors of nuclear fallout all experienced fatigue as a major problem..

10. Causes of fatigue Radiotherapy Accumulation of metabolites as a result of normal tissue damage (Greenberg, 1992) High anabolic processes involved in molecular and cellular repair ( Beach, 2001) ? Linked to anaemia where large fields or marrow producing bones are included in treatment area

11. Chemotherapy Neurotoxic drugs e.g. vinca- alkaloids Immunosuppression- release of cahectin 14 Magnesium depletion (Piper, 1981)

12. Surgery A naesthesia Analgesia Decreased ventilatory capacity Altered sleep patterns

13. Causes of cancer related fatigue l Physiological factors A. Cytokines tumours release chemicals known as cytokines- which affect the bodies metabolism. tumours also secrete macrophages and other immune cells, which produce and secrete cytokines

14. CNS effects The reticular activating system is believed to be the area of the brain controlling fatigue. Muscular Skeletal Effects Several abnormalities in muscle structure and function occur in cancer patients, even in the absence of cachexia/malnutrition. Cytokines are believed to have a major role in the development of these changes in muscle tissue.

15. l Biochemical and Endocrine Abnormalities l Hypocalcaemia l Diabetes l Hypothyroidism l Hypomagnesia l Polypharmacy l Haematological Abnormalities Anaemia: Controvesial

16. How is Hb mechanically associated with fatigue? Chemotherapy numbers of red blood cells are depleted Reduced O2 capacity damage/changes to the actual cell (Andrews, 2003) Quality as well as quantity affected

17. l Pain l Insomnia l Nausea l Constipation l Dyspnoea Studies have shown a link between the severity of physical symptoms and fatigue.

18. Dyspnoea is associated with the greatest fatigue. In a study by Thatcher (2001) looking at QOL in patients with lung cancer,all questionnaire respondents said that fatigue was their major debilitating symptom. These patients have a short survival time, therefore, they deserve more intense recognition and treatment of their worst symptom.

19. Fatigue is often accepted as “part of the illness” but it has a huge and often underestimated impact on patient’s quality of life Fatigue Leisure Social activities Relationships Self image Self care

20. Psychological factors Depression Personality type Stress : Cancer patients experience extreme physical, mental and environmental stresses.

21. Social and Environmental factors Gradual decline in social performance experienced by many patients may induce fatigue if not replaced by meaningful activities.E.g l loss of social contacts/activities. l Perceived inability to fulfil former role. l Increased reliance on others.

22. Assessment l Listen to the patient l Family support l Patient information and education “ Meaning before measurement”

23. Assessment tools Piper Fatigue Scale (Piper, 1988) The multidimensional fatigue scale (Smets et al, 1996) Fatigue assessment questionnaire (Glaus, 1998) Brief Fatigue inventory (Mendoza, 1996) Also QOL tools which contain a measurement of fatigue e.g. EORTC QLC C30

24. Fatigue Management Nursing Support and advice in hospital and community reinforcing advice from other team members. Medical correct any physiological causes e.g. Anaemia Allied professionals Social worker help in maintaining independence Dietician assistance/advice with maintaining good nutritional intake

25. Assessment and Monitoring Correct the Correctable Establish Their understanding of their illness, prognosis/treatment The nature of their fatigue Their coping mechanism How it affects their lives Their pre-morbid personality/lifestyle What they want to achieve

26. Treatment Balance of activity Pacing (5 minute more syndrome) Prioritisation Delegation of tasks Ergonomics Medication Analysis of current activity and fatigue levels e.g. use a simple fatigue inventory.

27. l Planning l Goal setting l Adaptation of environment/energy conservation advice l Support re managing family relationships l Relaxation l Advice and support re managing sleeplessness l Graduated exercise programme/ regular exercise l Advice re nutrition intake

28. Exercise Balance between exercise and rest Try to maintain a routine Regular light exercise if possible. Exercise has been shown to decrease fatigue as well as nausea and can improve sleep Drink fluids before and after exercise

29. Fatigue Management Exercise Physical activity may improve the QOL and physical performance of cancer patients during and after treatment. (British Journal of Sports Medicine,2001) Moderate intensity walking showed a significant improvement in physical functioning – no increase in fatigue Windsor et al, 2004) Results from Porock’s Study in 2000 showed walking programme for patients with advanced cancer IncreasedDecreased Activity levelsAnxiety QOL scores

30. Remember Fatigue is: l A Syndrome not a symptom l Correct what you can l Any intervention is a therapeutic trial l keep monitoring l Keep listening l Keep Positive